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Student Athletic Insurance Information

PARENTS: PLEASE READ AND KEEP PAGES 1 & 2 FOR FUTURE REFERENCE

We are extremely pleased to have your daughter/son as a student athlete at Greenville College and hope
she/he will achieve academic, social and athletic success.

EACH STUDENT ATHLETE IS REQUIRED TO:

1. COMPLETE & RETURN ALL ATTACHED FORMS by August 1st.

2. ALL FRESHMAN AND TRANSFER students must HAVE A PHYSICAL EXAM prior to any
participation in any intercollegiate sport, including official practice. Please get a physical
BEFORE coming to school. RETURNING STUDENTS DO NOT NEED A NEW
PHYSICAL, but must complete and return the rest of the packet before the first practice.

3. EVERY ATHLETE MUST HAVE PRIMARY INSURANCE and/or basic health insurance at
all times. College health insurance can be added if you are in need of primary coverage. If you
are currently covered by an individual or family plan, it is to your benefit to continue with this
coverage rather than purchase the college’s health insurance.

4. EVERY ATHLETE MUST HAVE ATHLETIC INSURANCE – a second layer coverage
through the college’s athletic insurance plan is required. This insurance is secondary and has
a deductible of $250. Any athlete who participates in practice will be billed for this athletic
insurance.

5. PLEASE NOTE The College has purchased an accident only policy that will cover a
maximum of $250 for athletic injuries (covers the deductible) and $5000 on non-athletic
injuries. This is also a secondary policy that will only pay out after your primary has paid their
portion.

6. USE ONLY THE AUTHORIZED MEDICAL VENDORS IF YOUR PRIMARY
INSURANCE IS AN HMO or PPO. (Contact with the HMO/PPO is the responsibility of the
student athlete or the family.)

7. GET AUTHORIZATION from the athletic trainer TO SEEK MEDICAL TREATMENT,
except in emergency cases.

8. FILL OUT A CLAIM FORM in the Athletic Trainer Office EACH TIME A NEW ACCIDENT
OCCURS. (Our athletic insurance carrier requires that all bills submitted must be accompanied by a
claim form in order to be processed. Without this, a delay in processing is inevitable.
CLAIM PROCEDURE:
1. Submit the bills incurred to your primary insurance carrier first. If a balance remains after your
insurance company has responded, SEND THE “EXPLANATION OF BENEFITS” from your insurance
company AND A COPY OF THE ITEMIZED BILLS to the company.
2. IF ADDITIONAL INFORMATION IS REQUIRED for claim processing, please respond
immediately so all paperwork can be processed in the least amount of time. It is in your best interest to
have the claim settled promptly since all bills incurred are in your name.
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ONE FIRM STATEMENT: The NCAA Division III does not permit any college or university
to provide coverage or pay bills incurred for expenses related to
illness or conditions not sustained as the direct result of an
ACCIDENT in our intercollegiate sports program.

INSURANCE COVERAGE: The college athletic accident insurance provides coverage for your
son/daughter for ACCIDENTS incurred while participating in the
play or official team practice of intercollegiate sports, including
sponsored and authorized team travel. Off-season
conditioning/lifting, games and practices are not covered.

$75,000 is the maximum amount per injury and the injuries are only
covered for two years.

ACCIDENT DEFINITION: An unexpected, sudden and definable event which is the direct
cause of a bodily injury, independent of any illness, prior injury,
or congenital predisposition.

An accident is determined by the following:
1. A specific time
2. A specific place
3. A specific occurrence
4. A specific trauma (i.e. contact with an external force)

EXCLUSIONS: Conditions not covered by athletic insurance

Glasses* Arthritis
Contact Lenses* Osteochondritis dissecans

* Covers injury of the eyes, but not breakage or loss of glasses or
contacts

Bills incurred beyond the policy benefit period.

Orthopedic appliances for participation unless prescribed by
physician.

Chiropractic visits (Physical Therapy visits shall be limited to $200
per visit and a maximum of $2000 per claim.

This policy will pay for claims that are denied by the HMO/PPO for
failure to follow their prescribed procedures up to a maximum of
$5000 per claim.

For a full list of benefits and exclusions contact Mike Peppler at
(618)664-6629 or at mike.peppler@greenville.edu

INJURIES OCCURRING ONLY DURING THE OFFICIAL SPORTS SEASON WILL BE
COVERED BY THE ATHLETIC INSURANCE!!!
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GREENVILLE COLLEGE
Student Athletic Insurance

Acknowledgement of Responsibility

_________________________________ Social Security # _______/________/______
Name of Student – (Please Print)

I, the undersigned, acknowledge receiving the information from Greenville College concerning athletic
insurance coverage and procedures.

I understand the limited extent of Greenville College’s responsibility to its student athletes in that:

1. Greenville College provides excess or secondary insurance coverage, which goes into effect
after receipt of Explanation of Benefits paid by the athlete’s personal insurance carrier. This
secondary coverage has a deductible of $250. Contact with any HMO/PPO will be the
responsibility of the student athlete or the parent/guardian of the student athlete.

2. Medical bills incurred, as a result of a coverage injury sustained by the student athlete during
the athlete’s participation in NCAA D-III sponsored sport, are ultimately the athlete’s
responsibility and could affect the athlete’s credit rating.

3. Greenville College, as per NCAA D-III regulations, cannot be responsible for illnesses.

4. Greenville College, as per NCAA D-III regulations, cannot be responsible for any injuries that
occur outside of officially designated intercollegiate practice or competition. (See Student
Athletic Insurance Information)

5. Referral of an athlete for precautionary medical attention by the athletic trainer to health
providers may not guarantee athletic insurance coverage. Greenville College cannot be
responsible for any medical bills incurred relating to pre-existing conditions, injuries or
illnesses.

I, the undersigned, will cooperate to the best of my ability to see that all medical bills incurred are filed
with the appropriate insurance carrier and that I quickly return any requests for information submitted to
me by Greenville College and/or its insurance carrier of record.

_____________________________________________
Parent – Guardian – Spouse (Circle One)

_______/__________/__________
Date
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Greenville College
Pre-participation Health History Questionnaire

Name: ________________________________________________________________________________
First Middle Last

SS#: ___ ___ ___-___ ___-___ ___ ___ ___ Sport 1: _____________________________

DOB: _________________ Sex: M F Sport 2: _____________________________

Grade: Fr SO JR SR 5th Sport 3: _____________________________

School Address: _________________________________________________________________________
Room Dorm PO # Phone#

Home Address: ________________________ Home Phone: (_____)____________
________________________ Cell Phone: (______)_____________
________________________ Email_________________________

Emergency Contact: __________________________________________________________
Name Relation
(H)(____)_______________(W)(______)_____________, (C)(____)_____________, (E)_______________
Phone Number- home, work and cell Email address

DIRECTIONS: PLEASE CIRCLE YES OR NO FOR EACH OF THE FOLLOWING QUESTIONS. FOR ALL YES
ANSWERS PLEASE EXPLAIN AT THE END OF THIS FORM. YOU MUST REPSOND TO ALL QUESTIONS.

1. Have you had or do you currently have:
a. A physical since you entered Greenville College? Date____/____/______________ Yes/No
b. An injury or illness since your last exam? Yes/No
c. A chronic or ongoing illness (such as diabetes or asthma)? Yes/No
d. Surgery or hospitalized, or had any emergency room visits? Yes/No
e. Any allergies to medications, insects, bee stings, foods, latex (circles those that apply) Yes/No
f. Anemia or any blood disorders? Yes/No
g. Any cause to be under a physician’s care since your last exam? Yes/No

2. Have you ever been advised by a physician not to participate in any sport? Yes/No

3. Have you had or do you currently have any of the following head related conditions?
a. Concussion requiring a physician’s evaluation Yes/No
b. Memory loss or loss of consciousness Yes/No
c. A seizure Yes/No
d. Frequent or severe headaches Yes/No

4. Have you or do you currently have any of the following heart conditions
a. Chest pain or palpitations Yes/No
b. Heart Murmur Yes/No
c. High Blood pressure Yes/No
d. Restriction from sport for heart problems Yes/No
e. Has any family member or relative:
1. Died or a heart problem before age 35 Yes/No
2. Died of a heart problem before age 50 Yes/No
3. Died with no known reason Yes/No
4. Died during or after exercise Yes/No
5. Had Marfan’s syndrome Yes/No
5. Do you take any prescribed medications or over the counter medication on a regular basis
including medication for asthma? Please list ____________________________________ Yes/No
________________________________________________________________________

6. Do you have, need or carry any of the following: (check all that apply)
____Contact lenses, ____eye glasses, ___hearing aides/implants, ___orthodontic braces
____Orthopedic/protective braces for_____________________, ___epic-pen, ____inhaler
body part
___insulin pump, _____wear medic ID bracelet/necklace for___________

7. Have you had or currently have any of the following neuromuscular/orthopedic conditions:
a. A burner, stinger or pinched nerve Yes/No
b. A sprain Yes/No
c. A strain Yes/No
d. Swelling or pain in muscles, tendon, bones or joints Yes/No
e. Low back pain Yes/No
f. A dislocated joint Yes/No
g. Fracture(s) or stress fracture(s) Yes/No

8. Have you had or do you currently have any of the following general or exercise related conditions
a. Difficulty breathing Yes/No
1. after running 1 mile Yes/No
2. coughing wheezing or shortness of breath in weather changes Yes/No
3. been told you have exercise induced asthma Yes/No
4. experience dizziness, passing out or faintness Yes/No
b. Viral infections (i.e. mono, hepatitis) Yes/No
1. become tired more quickly than your friends Yes/No
c. Any of the following skin conditions Yes/No
1. acne, contact dermatitis, ringworm, warts, herpes, impetigo Yes/No
2. sun sensitivity Yes/No
d. Weight loss/gain (greater than or less than 10 pounds) Yes/No
1. do you want to weigh more or less than you do now Yes/No
e. Ever had feelings of depression Yes/No
f. Heat related problems (dehydration, dizziness, fatigue, headache) Yes/No
1. Heat exhaustion (cool, clammy, damp skin) Yes/No
2. Heat stroke (hot, red, dry skin) Yes/No
3. Heat cramps Yes/No
9. Have you ever had an athletic injury and/or surgery to the following: (if so give date and explain)
a. Shoulder Yes/No ___________________________________________________________________________
b. Hand/wrist Yes/No ___________________________________________________________________________
c. Knee Yes/No ___________________________________________________________________________
d. Ankle Yes/No ___________________________________________________________________________
e. Back Yes/No ___________________________________________________________________________
f. Abdominal Yes/No ___________________________________________________________________________
g. Chest Yes/No ___________________________________________________________________________
10. Females only:
a. do you have any menstrual irregularities Yes/No
11. Explain all “Yes” answers here(include dates)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_____________________________________________________________
I hereby state that to the best of my knowledge, my answers to the above questions are correct.

Athlete’s signature:______________________________________________________ Date_______________________

Please note that if you were restricted from physical activity for any reason within the past year you must have a
signed Release to participate form from the physician that treated you.
Date_________________
GREENVILLE COLLEGE ATHLETIC PHYSICAL FORM

Name College Credit Hours Earned
Social Sec # Class 1 2 3 4 Sex
Home Address Age ______ Birth date
Single ______ Married
Home Phone
Sport of Interest ____________________________ Transfer Student No Yes

Do NOT fill in below this line

PREVIOUS ILLNESS

ARE YOU ON ANY MEDICATIONS (include allergy medication)

________________________________________________________________________________________
IMMUNIZATIONS
OPERATIONS:
SYSTEMATIC E.E.N.T.
REVIEW
Cardio-Resp: any heart disease _____, rheumatic fever _____, pneumonia _____, asthma _____
Genito-Urinary: Kidney infection
Menstrual problems

Nervous: mental breakdowns _____, treatment _____, hospitalization
Convulsions
Epilepsy
Emotional Evaluation
Extrem. ____________________________ Any broken bones
Gastro-intestinal _____________________ Ulcers
HISTORY OF T.B.
HISTORY OF DIABETES

PHYSICAL EXAMINATIONS

Check Normal Abnormal Remarks
Throat
Nose
Height
Ears Weight
Eyes B.P.
Thyroid Pulse
Lymph glands
Heart
Lungs Urinalysis
Abdomen Sugar
Hernia Albumin
Skin Microscopic
Back (When Indicated)
Extremities
Reflexes This patient is recommended for:
Impression Intercollegiate Sports
Restricted Activity
No P. E.

Date ____________ M.D.
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Student-Athlete Authorization/Consent
For
Disclosure of Protected Health Information

I hereby authorize the physicians, athletic trainers, sports medicine staff and other health care
personnel representing Greenville College and the Greenville College Athletic Department to release
information regarding my protected health information and any related information regarding any injury or
illness during my training for and participation in intercollegiate athletics. This protected health
information may concern my medical status, medical condition, injuries, prognosis, diagnosis, athletic
participation status, and related personally identifiable health information. This protected health
information may be released to other health care providers, parents/guardians, hospitals and/or medical
clinics and laboratories, athletic coaches, strength and conditioning coaches, medical insurance
coordinators, insurance carriers, medical supply vendors and/or service companies, academic counselors,
athletic and/or university administrators, chaplains and/or clergy members, NCAA Injury Surveillance
System, sports information staff and members of the media.
I understand that my authorization/consent for the disclosure of my protected health information is
a condition for participation as an intercollegiate athlete for Greenville College. I understand that my
protected health information is protected by federal regulations under either the Health Information
Portability and Accountability Act (HIPAA) or the Family Educational Rights and Privacy Act (FERPA)
of 1974 (the Buckley Amendment) and may not be disclosed without either my authorization under
HIPAA or my consent under the Buckley Amendment. I understand that once information is disclosed per
my authorization/consent, the information is subject to re-disclosure and may no longer be protected by
HIPAA and/or the Buckley Amendment.
I understand that I may revoke this authorization/consent at any time by notifying in writing the
Head Athletic Trainer, but if I do, it will not have any effect on actions Greenville College or Greenville
College Athletic Department took in reliance on this authorization/consent prior to receiving the
revocation. This authorization/consent expires six (6) years from the date it is signed.

_________________________________ _________________________ ______
Name of Student-Athlete (print or type) Signature of Student-Athlete Date
Greenville College

Athletic Department
Release of Information

I, _______________________, give my permission for the release of medical information to my athletic
participation at Greenville College to the Athletic Department

Requested Information:

_______ Surgical Reports/Records

_______Physician Reports/Records

_______Office Notes/Records

_______Reports from MR, X-Ray, Bone Scan, or other special tests

_______Rehabilitation Record

_______ Other______________________

Please fax or mail the above requested information to the following:

Phone: 681-664-6629 Head Athletic Trainer
Fax: 618-664-1060 Greenville College
315 E College Ave
Greenville, IL 62246

____________________________________ __________________________
Print Name Date

_____________________________________ ____________________________
Signature Social Security Number
Insurance Information

The following information is needed when filing a claim for an intercollegiate accident.

1) Father/Guardian Name Phone Address(street, city, state, zip)

2) Father/Guardian Employer Employer Address Business Phone

3) Mother/Guardian Name Phone Address (street, city, state, zip)

4) Mother/Guardian Employer Employer Address Business Phone

A) Please make a copy of the front and back of the primary insurance card(s) and attach.
B) Or fill in the following information.

Name of primary insurance company: _______________________________________________
Address: ______________________________________________________________________
Phone #_______________________________________________________________________
Policy/ID #____________________________________________________________________
Group #_______________________________________________________________________
Is this policy an HMO: Yes No
Is this policy a PPO: Yes No

A reminder- the secondary insurance policy will only cover injuries sustained during official school
sponsored practice or games. It does not cover off-season conditioning/lifting, captain’s
practices/games or intramural, club, or pick up practice/games. It also does not cover illness or
disease even if they occur during intercollegiate participation.

Secondary Insurance Information
Carrier: The Baker Agency, Inc
962 Industrial Parkway
PO Box 390
Plainwell, MI 49080
Phone: 800-223-1318 Fax: 269-685-8819 wedsite: bakerathletic.com
Policy Number: USO25568

Claims Processor: NAHGA Claim Services
PO Box 189
Bridgton, Maine 04009-0189
800-952-4320 Fax-207-647-4596